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Obstructive Sleep Apnea

Who should be treated?

The decision about whether you need treatment must be made in consultation with your doctor. Obviously if you suffer from the classic symptoms of sleep apnea with daytime sleepiness and alterations in your mental function or personality, then treatment will be of great importance to you. But some people with sleep apnea are surprisingly unaware or free of symptoms. Do these people need treatment? Maybe. Even asymptomatic patients may be at risk for the cardiovascular complications of obstructive sleep apnea. You may be at risk of developing hypertension or other medical complications, even if you do not have severe apnea or marked drops in oxygen levels at night. The decision should therefore be based on both symptoms and signs of sleep apnea after review with your physician.

Medical Treatment Options

Body Position

Sometimes relatively simple measures can help sleep apnea. Some patients may only have apneic episodes when sleeping on their backs. If they can stay on their side apnea may be reduced or eliminated. Unfortunately this is more difficult to achieve than it would seem. One suggestion has been to sew something such as a tennis ball into the back of the pajama top. Another suggestion by a patient was to use a pinecone! In addition to the lateral position, elevation of the head of the bed by about 30° will also substantially decrease apnea in some patients.

Weight Loss

The severity of obstructive sleep apnea is also related to weight in many though not all patients. Even modest weight loss may significantly decrease apnea. In general a 10-15% weight loss will decrease the severity of apnea by half.

Alcohol Avoidance

Most agents that cause sedation will somewhat worsen OSA. Clearly, however, alcohol is the most important. Alcohol results in a decrease in upper airway tone and often leads to marked worsening of OSA. Avoidance or at least decreasing the amount of alcohol, especially close to bedtime, is of great importance in managing sleep apnea medically. If the patient is on treatment such as CPAP, then modest amounts of alcohol may be better tolerated.

Hypothyroidism (low thyroid hormone)

Untreated hypothyroidism has been associated with OSA. This may be due to the body changes that occur, the size of the thyroid gland or the effects of low thyroid hormone on breathing pattern. Treatment may help, but usually the improvement is not enough to completely treat OSA and eliminate the need for other treatment.

Electrical Stimulation of the Upper Airway

Since OSA occurs when the muscle tone in the throat (pharynx) is not strong enough to hold the airway open, it would seem logical that if the muscles were stimulated the apnea would be corrected. There is promising research in this area, which does suggest this may be the case. Unfortunately, no device is readily available for clinical use yet.

Nasal Dilators

Since resistance to airflow in the nose increases airway collapse in OSA, reducing nasal obstruction would seem likely to help. Several devices that dilate the nose, both internal and external, are available. While they seem to help some snorers, no significant consistent benefit for sleep apnea has been seen.

Medication

Antidepressants have been tried for sleep apnea. None has proven to consistently or completely treat OSA though some improvement is sometimes seen in the severity of apneic episodes. There is ongoing interest in finding a medication that would help but no immediate choice is available now.

Continuous Positive Airway Pressure (CPAP)

CPAP involves the delivery of air (not oxygen) under pressure to the pharynx. This pressure acts as an air splint, holding the airway open and preventing the partial or complete collapse that is the main event in OSA. Usually this is delivered through a mask that fits over the nose only. In almost all cases this eliminates the signs and symptoms of OSA as well as the snoring. Most patients get relief quickly, some the first night they use it. In others it may take 1-2 weeks to adapt to the sensation of using the machine. (Graph of effect of CPAP) (Pictoral/cartoon demo of effect of CPAP)
CPAP was first used in Australia in 1981. The major difficulty then, and now, was devising a mask to fit comfortably but snuggly over the nose. Since the first masks a great deal of research has gone in to finding comfortable masks. There are now a variety of masks of different designs and different materials. Most still fit over the nose but some are designed to fit into the nasal opening. These are particularly helpful if you have any degree of claustrophobia. Because some patients cannot adapt to nasal breathing, masks that fit over both the nose and mouth are also available. There are also newer units, which actually adjust the amount of pressure as needed throughout the night. For some people this is more comfortable. Another choice for difficult cases, particularly for those with more severe OSA, is BIPAP or bi-level CPAP where the pressure during inspiration can be different than during expiration. This too can be more comfortable for some, especially when high pressures are needed. (Link to more detail in the CPAP education section.)

Surgical Therapy for OSA

For some patients CPAP is not an acceptable choice. This may be because of their inability to tolerate it or just unwillingness to use it. Many of these patients are candidates for surgery.

Surgery for sleep apnea focuses on correcting the obstruction of the upper airway. The goal of surgery is cure of sleep apnea, which means relief of the obstruction. Obstruction of the upper airway can occur at several levels including the palate, the base of the tongue or both. Surgery is aimed at correcting whichever obstruction is present. Nasal obstruction may also be present and contribute to the tendency for the airway to collapse, even though it is rarely the sole cause of OSA. When present along with other areas of obstruction, it may be important to correct this problem as well. This may be the first surgical procedure tried. In some cases, correction of a nasal problem will then ease the use of CPAP so that no further surgery is needed.
If examination reveals that the soft palate is contributing to obstruction then removal of some of the palate, the uvula and any remaining tonsillar tissue may be of help. (Called uvulopalatopharyngeoplasty or UPPP) Overall there is success with this surgery alone in 20-50% of all patients. The surgery is not complicated or dangerous, but is quite painful. Alternatives to this include creating a flap of tissue rather than complete removal. This is less painful. Lasers have also been used but are generally less successful.

The relatively low success of UPPP alone led to development of modifications. These changes involve surgery to the muscle attached to the tongue, tightening it so the tongue does not fall backward against the back of the throat during sleep, something that is common in OSA. In some patients an additional procedure in which a small bone called the hyoid is pulled forward, creating more space at the base of the tongue. Both of these procedures increase the chance of success, usually to greater than 60%.
Recently a new technique has been used to shrink the volume of tissue in the upper airway, radio frequency wave ablation (pioneered by a company named Somnus and labeled somnoplasty). This involves a small probe being placed into the tissue of the nose, base of the tongue or throat and applying high energy waves. It is effective in decreasing the volume of tissue and helps snoring. It may also help sleep apnea as well though this data is not as clear. It can also be used in conjunction with surgery for OSA. The big advantage is that it is an outpatient procedure and much less painful than most other techniques to reduce tissue in the upper airway.

In the remaining patients, further surgery on the jawbones themselves may be necessary to create a larger airspace and prevent obstruction during sleep. This is more aggressive but the results are a high success rate, approaching 100% in curing sleep apnea.

Oral Appliances for OSA

In the last several years, many devices, which can be worn inside the mouth, have been tried for sleep apnea. The goal is generally to hold the mandible (lower jaw bone) in its normal position or to pull it slightly forward. This prevents the jaw and tongue from falling backward during sleep and causing obstruction. There have been as many as 55 devices tried with largely the same goal. More recent ones allow some adjustability of the jaw position. The devices are generally well tolerated if the patient has no major tooth or jaw problems to begin with. They seem most helpful in mild to moderate cases but some success has occurred in more severe cases as well. The success is not like that with CPAP but offers an alternative to those who cannot use CPAP and may not want or be candidates for surgery.